Microvascular Decompression Technique for Trigeminal Neuralgia Using a Vascular Clip

Microvascular decompression (MVD) surgery is a well-established, effective treatment option for trigeminal neuralgia¹ and hemifacial spasm.² In 1967, Janetta et al³ introduced the concept of MVD surgery and pioneered the Janetta technique in which Teflon felt implants are placed between the trigeminal nerve and offending vessel. Though many cases are successfully managed with Teflon interposition, alternative techniques have been developed with the objective to alleviate vascular compression symptoms indefinitely, including transposition using biological glue,⁴ vascular clips,^5,6 and a variety of “sling” techniques.⁷ In Video 1, we demonstrate a fenestrated clip transposition technique in the treatment of trigeminal neuralgia. We present the case of a 72-year-old female who presented with classic trigeminal neuralgia pain along the V2 and V3 distributions. Magnetic resonance imaging revealed evident compression of the trigeminal nerve by the superior cerebellar artery (SCA). A retrosigmoid craniotomy was performed, and the vascular loop of the SCA was visualized compressing the root entry zone with significant indentation of the trigeminal nerve. Wide arachnoid dissection along the SCA was carried out in order to mobilize the SCA away from the nerve. A small slit was created in the undersurface of the tentorium, and then the SCA loop was transposed to the tentorium using a fenestrated aneurysm clip. The postoperative course was uneventful, and the patient had complete resolution of her facial pain at 6-month follow-up. This method is likely an effective and durable method of decompression for trigeminal neuralgia.